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Lichen sclerosus in males

MALE GENITAL (PENIS) LICHEN SCLEROSUS

What are the aims of this leaflet?

This leaflet has been written to help you understand more about male genital lichen sclerosus (also known as balanitis xerotica obliterans). It tells you what this condition is, what it is caused by, what can be done about it, and where you can find out more about it.

What is male genital lichen sclerosus?

Lichen sclerosus is a chronic inflammatory skin condition which can affect any part of the skin, but in men is most often seen on the foreskin and tip of the penis. Lichen sclerosus in men does not usually affect the skin around the anus. It can affect boys or men of any age.

In some people, lichen sclerosus also affects the skin elsewhere on the body, where it can cause whitish patches of skin, but usually no discomfort.

What causes a male genital lichen sclerosus?

What causes lichen sclerosus is not fully understood. It almost never occurs in men who have been circumcised early in life.

Lichen sclerosus is not caused by an infection, and although the genital area is affected, it cannot be passed to a sexual partner.

Lichen sclerosus may affect some men with auto-immune diseases such as thyroid disease or diabetes, although this link is more common in women. It may also be linked to atopic conditions such as eczema, asthma and hayfever.

Friction or damage to the skin can bring out lichen sclerosus and make it worse. This is called a ‘Koebner response’, and is sometimes seen after surgery. Some men dribble a small amount of urine after passing water, and it is thought that trapping of urine under the foreskin may bring on male genital lichen sclerosus.

There is a link in some men between lichen sclerosus and penis cancer, but it is rare. Although circumcision may reduce the risk, it does not absolutely prevent penis cancer.

Is male genital lichen sclerosus hereditary?

Although there are some reports of familial lichen sclerosus, it does not usually run in families.

What are the symptoms of male genital lichen sclerous?

The affected skin may feel uncomfortable, sometimes itchy, burning and sore, especially during or after sex. Often the foreskin gets tighter and more difficult to retract, leading to painful erections. The skin may tear and bleed during sexual intercourse.

When the opening in the tip of the penis is affected, the urine may spray. Some men, however, do not experience any symptoms./p>

What does male genital lichen sclerosus look like?

The affected skin of the penis can look red, with little cracks, sores, bleeding points or small blood-blisters. When the skin has been inflamed for some time, it can turn white and become thinned. On the other hand, thickening of the skin may also sometimes be seen. Scarring can develop and change the appearance of the foreskin or tip of the penis. When the tightened foreskin is retracted, it may draw in around the shaft of the penis like a tight band (‘waisting’).

Sometimes the foreskin may be too tight to withdraw, making it impossible to clean the end of penis. If this happens then it is important to seek advice from a doctor, as there may be an increased risk of cancer if this problem is left untreated.

How is male genital lichen sclerosus diagnosed?

The diagnosis is often made by a dermatology doctor after looking at the affected skin.

Sometimes a small skin sample may be taken and checked under the microscope to confirm the diagnosis, especially if there is an open sore or a thickened area of skin. This is known as a skin biopsy and requires a local anaesthetic injection and possibly stitches to close the wound, leading to a small scar.

Can male genital lichen sclerosus be cured?

Although circumcision can cure lichen sclerosus in some men, in others the condition may continue or change after surgery. Lichen sclerosus will not go away on its own, but may not cause any symptoms when certain creams are used.

How can male genital lichen sclerosus be treated?

Strong steroid ointments such as clobetasol propionate (Dermovate®) and diflucortolone valerate (Nerisone forte®) are used to stop the inflammation and also soften the affected skin. This reduces the need for surgery. Please do not worry about the warning inside the pack, where it might say not to use these ointments on genital skin - your dermatologist will advise you how and when to apply the steroid ointments safely.

After the initial treatment period, a maintenance treatment plan may be required. This may include the regular use of moisturisers and intermittent use of steroid creams, which may be less strong. National guidelines on the safe use of these in genital lichen sclerosus have been published (see the reference below).

Tacrolimus and Pimecrolimus ointments are not usually used as first line treatment in lichen sclerosus. They do not cause skin thinning, although there are theoretical concerns about increasing the risk of skin cancer.

If the foreskin becomes too tight to function properly and is not softened by creams, referral to a urologist for circumcision or other surgery should be considered. This may cure the lichen sclerosus, even on the shaft and tip of the penis.

If the opening at the tip of the penis becomes so narrow that urine cannot pass through it easily, the urologist may recommend how to gently stretch it and / or apply steroid ointments to that area and, failing this, consider surgery.

Self care (What can I do?)

  • Avoid washing with soap and instead use an emollient soap substitute/ cream to wash. Many different non-perfumed creams can be used, however aqueous cream can lead to irritation in some men and may need to be avoided.

  • Carefully dry yourself after passing urine to reduce the contact of urine with your skin.

  • Using a moisturiser or yellow soft paraffin as a barrier cream can protect your skin from exposure to urine.

  • Keep pubic hairs trimmed so they do not get trapped between the foreskin and the penis.

  • A lubricant for sex will reduce excessive friction.

  • If you are a smoker, stop smoking to reduce the risk of penis cancer.

  • Lifelong regular self-examination is very important for all men who have or have had genital lichen sclerosus. If any skin change develops which does not respond to steroid creams, in particular any persistent skin thickening or soreness, you need to tell your doctor without delay. You may need a biopsy to test for skin cancer.

Where can I get more information about male genital lichen sclerosus?

Web links to detailed leaflets:

http://dermnetnz.org/immune/lichen-sclerosus.html

http://www.patient.co.uk/health/Lichen-Sclerosus.htm

 Link to patient support group:

www.lichensclerosus.org

Published guidelines for the management of lichen sclerosus: British Journal of Dermatology 2010, 163: 672-82

For details of source materials used please contact the Clinical Standards Unit (clinicalstandards@bad.org.uk).

This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.

This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel

BRITISH ASSOCIATION OF DERMATOLOGISTS

PATIENT INFORMATION LEAFLET

PRODUCED AUGUST 2013

UPDATED OCTOBER 2016

REVIEW DATE OCTOBER 2019

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